18664 APPLICANT TO FILL IN INFORMATION WITHIN+RED LINES - USE BALL POINT PEN ONLY"
BU LDING PROJECT IDENTIFICATION " .PERMIT NUMBER
ADDRESS LDING APPLICATION'&'PERMIT ^
BUILDING -ELECTRICAL-PLUMBING=MECHANICAL N- .
OWNER'S
NAME PLAN CHECK VALIDATION
1 CITY. ELECTRIC PERMIT FEE
C7�11AGe QST m�u�cr PRDNE I'�`6 Gln
CTOR'S
NAME �•'j��ft`�/��1
NAME } p UTLETS-SWITCHES-RECEP 10.00/1.00
-61-1(� 1J11`� uc.ND.•4'[y r LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'Sp��� T
'
ADDRESS /1 PPLIANCES-RESIDENTIAL 4,00 '
PANELS " 10,00 . DATE OdF gPPLICATION
ARCM TECT PLAN CHECK FEE P;C.NO.
OR PANELS (OVER 200 AMP) 20.00 -
ENGINEER
' •uc.rv0. SIGNS TRANS. 3.00
A RCH.OR ENG. „ - - PERMIT VALIDATION
ADDRESS .SPECIALCIRCUIT. 5.00
. zIP EMP.METER OR POLE INS. - 20.00
A //
ADOP ESNT'S oR Ess� MOTORS SEE,FEE SCH. P A D
E CWADIG 20.00 AA,,pp�� yq Q .dee`
d r '1YIO d vIJ�7�
F o.o LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 9 1• _
n G w y (commencing with Section 7000)of Division 3 of the Business and r1 ISSUANCE qGATE
-H A 2 Professions Cad-,and my IlCense Is In full force and effect. A gggyLyOC I(1♦ MECH.
oz w a License'Class Lin.Namber 1� y
H m H J Date Contractor CC147 k LLII
Q y E J
rt C w ¢ OWNER-BUILDER DECLARATION BUILDING PERMIT
`xt °; n H I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
INFORMATION
i LL < Lawforlhe following reason. 7031.5,Bmaneasand Professions ,fid VALUATION $/FT.
m m J ;DRAINS-FZLOOR,
CE 10.00
� � Code:An}'eltyorcounty which req tires a permit tocons[ruct,elter, -
¢O improve,demolish,or repair any structure,Prior to its issuance,also ELEC. LIC.NO. ELEC.is, requlresthe applicant for suchpermoohat + TOTAL -�PERM TO
e. ac m"' he is licensed pursuanttothepions ofthe Contr;mtor's Licensea- Law(Chnpler9( ommenoing with Section 7000)of Division3 of th4 e' Business andPofessionsCode)orThalheised OTY. BING PERMIT - FEEthe basis forthealleged exemptionAnyviolat1.5ST RIES -TYPE CONSTR.
i ;,� by anyapplcantforapermitdolkitsa$5epFllltyVENT-WATER (EA.): 5.00ofa morehanfivehundred dollars $500))❑ Laswner of the property,or my employees with waes as TECT.DEVICE 4.00thrsolecompensationwilldorheworkand the structure is n0t OCC.GROUP RES.UNITS
irparled or offeredfogssle (Sec7044;Busns ,ROOF,AREq CON D. 5.00
Code:The Comractor's License Law does not apply to an owner of -
propertywhobuildsorimprovesihereon,and who docs such'work FIXTURES.-PER TRAP ; - 5.00se.FT.FLOOR AREA-TOTAL ACREAGE
himself or through his own employees,provided that such improve-
memsareoutintendedorofferedforsWe'If,however,the budding GAS-EA.SYSTEM-11NC.4 OUTLETS 6.00 or improvement is sold within one year of completion,the owner - GAS,m EA:SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale:). - RES IND CON PB Other r `
O 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 El El ElE] 1-1licensed contractors m construct the project(SIC. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. . 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 -
- Contracts for such projects with a contractor(s)licensed pursuant to '
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 ' TRACT NO: PARCEL NO.
re❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner -.Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION- WATER TREATING EQUIP. 5.00
"'I hereby affirm that I have a certificate of consent to self-insure,
/ or a certificate of Workers'Compensation,Insurance,or a certified ZONING-
P ENG.SITE NO.
copy the4�e�Q c.38 ,Lahy 'C2 1,0r �p rak r
Policy No7i�any
Q ❑ Certified py is here fur III}e
/p FIRE SPRINK ENERGY T-
-Z �' Certifi rr � h 1 'ibx insr `p-elivision. 24
F _ 'Applicant y/tl MISC.- REFERTOORD. YE] N� YEl 'NE]
may '' CE TIPICATEOF EXEM N FROM WORKERS' PERMIT ISSUANCE 10.00 FLo00 zoNE, q.L.0 c. '
W'� ! COMPENSATION INSURANCE PLG.CONTR. uC:No. - PLG. '
�• fThis section need not be Completed if the permit is for one ' TOTAL Y Q N Q Y Q' NEI
Z hundred cl.11ms($100)or less)
U.O 1 certify tbal in the performance of the work for which this per-' CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so us to
U W became subject to the Workers'Compensation Laws of California. -
rl Date Applicant ALTER.OR ADD TO MECH'. 5.00 'BUILDING
} h NOTICETO APPLICANT: If,after making this Certificate of Ex-
emption,you should become subject,to the Workers'Compensation APPLIANCE 5.00 .PLAN CHECK
provisions of the Labor Code, you must forthwith comply with U FEE such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MOC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY .. AIR HANDLING UNIT(OVER 1000DQRM.) 6.00 SEISMICFEE
I hereby affirm that there is a construction lending agency for .' EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. + , MICROFILM
3097,civ.c.). - ; _ HEATING UNIT(TO 100,000'B:T.U.) 8.0
Lender's Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC +
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4,00
' information is correct 1'agrcc to comply with all city and county PLUMBING
ordinances and state laws relating to budding construction, and BOILER-COMP(3H.P.or 100,00013 T.U.),6,00 _
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTUI SEE FEE'CH
above-mentioned'property for inspection purposes. MECHANICAL
(We)-agree to save, indemnify, and keep;hatmless the City of MISC.- REFER TO ORD. ^
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE CONST.TAX
may 1 any sea$$ a. u against�CitYonsequence of the - 1000 m- g pf(his fSer i MECH.CONT. LID.NO. MECH.l/ri I¢ `�B'Cl TOTq nature of AppUale �7,
OFFICE,COPY .